Description:

E2906 Abbreviated Comprehensive Geriatric Assessment Battery NCT01041703 Clofarabine or Daunorubicin Hydrochloride and Cytarabine Followed By Decitabine or Observation in Treating Older Patients With Newly Diagnosed Acute Myeloid Leukemia Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7586A704-3044-A522-E040-BB89AD4359F8

Link:
https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=7586A704-3044-A522-E040-BB89AD4359F8
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  1. 9/19/12 9/19/12 -
  2. 8/11/14 8/11/14 - Martin Dugas
  3. 1/8/15 1/8/15 - Martin Dugas
  4. 6/8/15 6/8/15 -
  5. 9/20/21 9/20/21 -
Uploaded on:

September 20, 2021

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License :
Creative Commons BY-NC 3.0 Legacy
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E2906 Abbreviated Comprehensive Geriatric Assessment Battery NCT01041703

INSTRUCTIONS: Please complete this form according to the forms submission schedule. Submit original to the ECOG Coordinating Center. Keep a copy for your files

Header
On Treatment
On Treatment Report Period (Choose one)
Data amendment
Assessment Date
Mini Mental Examination Section
Gds
Do you feel that your life is empty
Do you feel happy most of the time
Do you often feel helpless
Do you feel pretty worthless the way you are now
Adl
Bathing (sponge bath, tub bath or shower)
Transfer
Continence
Can you go shopping for groceries
Can you prepare your own meals
Can you do your own housework
Can you do your own laundry
Section Ii - Social Support
Someone you can count on to listen to you when you need to talk
Someone whose advice you really want
Someone whose advice you really want
Someone to share your most private worries and fears with
Someone to share your most private worries and fears with
Someone to turn to for suggestions about how to deal with a personal problem
Someone to turn to for suggestions about how to deal with a personal problem
Someone who understands your problems
Section Ii - Social Support
Someone to help you if you were confined to bed
Someone to take you to the doctor if you needed it
Someone to prepare your meals if you were unable to do it yourself
Someone to help with daily chores if you were sick
Comorbidity Questionnaire
Have you ever had a heart attack
Have you ever been treated for heart failure (You may have been short of breath and the doctor may have told you that you had fluid in your lungs or that your heart was not pumping well.)
Do you have other heart disease
Have you had an operation to unclog or bypass arteries in your legs
Have you had a stroke, cerebrovascular accident, blood clot or bleeding in the brain, or transient ischemic attack (TIA)
Do you have difficulty moving an arm or leg as a result of the stroke or cerebrovascular accident (If yes)
Do you have asthma
Do you take medicines for your asthma (If yes check one box)
Do you have emphysema, chronic bronchitis, or chronic obstructive lung disease
Do you take medicines for your lung disease (If yes check one box)
Comorbidity Questionnaire1
Do you have stomach ulcers, or peptic ulcer disease
Do you have diabetes (high blood sugar)
How is it treated (If yes check one box)
Has the diabetes caused any of the following problems (If yes)
Have you ever had the following problems with your kidneys
Do you have arthritis
Do you take medications for it regularly (If yes)
Do you have any of the following conditions
How often do you see your dentist
Medications/sexual Function
On average, how many prescription medicines do you take each day
On average, how many non-prescription medicines (over-the-counter) do you take each day
During the last 4 weeks, did you have sexual intercourse
Over the past 4 weeks, how would you rate your level of sexual desire
Weight
Kg
Kg

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